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(0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> F Telephone: , (209) ,466-6781 <br /> ,y _ 7 <br /> t APPLICATION FOR WELL ,CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 .Year From Date Issued <br /> -. Complete In Triplicate <br /> Application is hereby made to the San' joaquin. Local Health District for a permit to construct <br /> and/or install the work herein -described.' This application is made in compliance with San <br /> Joaquin 'County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 3 O �`��- r S CITY/TOWN 4 iS - cj-� <br /> Owner's Name D i i 4 e- Phone <br /> Address g / i�! < �--�P City . <br /> Contractor's Name Li cense#/U hone_ 7- -71 ? _ <br /> IS CERTIFICATE OF WORKMAN'S CMTENSATIO111 INSURANCE ON FILE WITH SJLHD? YES - NO <br /> TYPE OF WORK (Check) : NEW WELL Ca DEEPEN ❑ RECONDITION [ DESTRUCTION[j . <br /> WELL CHLORINATION 0 WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION C] PUMP REPAIRCS PUMP REPLACEMENT [I <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY (1� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL -- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 7 Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other - Other Information <br /> Geophysical n Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> Type"of Pump M H.P. <br /> 4 PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: pState Work Done n � ��� <br /> DESTRUCTION OF WELL: We11LDiameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT IN TI P TO GR UTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: DATE: <br /> (DRAW PLOT PLDN ON REVERSE SIDE <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE 17 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : i <br /> PHASE II GROUTPINSPECTION PHASE IIJ FIN8L INSPECTION <br /> INSPECTION BY DATE INSPECTION DAT <br /> C'u' i A9r, Dna, 19-77 1/78 2M <br />